The Skin We’re In: Because sometimes beauty really is skin deep.
Anyone who’s experienced hormonal acne knows that your skin can have an effect on your mental health; nothing in my teenage life was more stressful than a poorly timed breakout. So it seems plausible that the reverse could be true, and your emotions could also affect your skin. What I did not know until recently was that there was anything to do about it besides complain, and apply copious amounts of expensive skin-soothing products.
Here’s where Matt Traube, a licensed clinical therapist who specializes in psychodermatology — one of few across the country — comes in. Psychodermatology is the science of how your feelings affect your face. We talked to Traube to learn more about the field, the mind-skin connection, and how it’s possible to improve one’s skin by addressing one’s mental health.
What exactly is psychodermatology, and how did you get into this field?
It was through my father. He first learned about the field of psychodermatology while he was getting his Ph.D. at Boston University, and had worked with some psychologists there who realized the impact that our emotions have on our skin. And so of course, being around him, I learned about it at a very early age.
I remember being about 10 and having a wart on my finger. My father said, “Oh, no problem, I’ll get the wart medicine.” He whispered something to my brother, and my brother filled up a small, empty shampoo bottle with various salad dressings from the fridge. My father came back and he said, “Here’s the medicine,” and he put it on my finger. And within a day or two, the wart disappeared. I think my belief in the medicine helped the warts go away faster than they would have otherwise.
What I didn’t understand yet was this amazing mind-body connection between how we feel, how we think, and our skin. Now I have patients call because they’re worried about acne, and they notice that their acne increases during stressful times. I think most people have had that experience. What’s been very cool is that there is more and more good research that’s coming out to support this idea of the mind and skin connection.
When we think about very basic psych issues — things like anxiety, stress, anger, depression — it turns out, that impacts our nervous system. If you’re somebody who is anxious, and you feel unsafe, the nervous system escalates, and that has a link to different skin issues. A lot of people I see will say, “My skin flared when I ate this food, or when I was in contact with something,” as well as, “My skin flared when I was thinking about getting married, or when I went through an emotionally challenging time.”
Even having acne is a very subjective thing. Five people could have the exact same amount of acne, and three people could feel absolutely terrible about what they have, one person could care less and think everything’s fine, and the fifth person could feel completely different. It’s a chicken-and-egg scenario: Sometimes when people feel really stressed, they notice their acne increases. But it’s hard for people to figure out if the stress is causing acne, or if the acne is causing more stress, and compounding it.
Are you able to test the effects of stress on skin, specifically? It seems like it would be hard to isolate that factor from all the others that might impact your complexion.
It’s true that it’s multifactorial. But think about something like blushing from embarrassment, or turning red from anger. We’ve all experienced that direct connection between the psychological state of the mind and the physiological expression through the skin. And there’s research, too, about how when we get stressed or anxious, there are some inflammatory molecules released in the body — there was a big study that came out earlier this year about the link between acne and depression.
For patients who come to you with skin issues you suspect are tied to something mental or emotional, how do you approach their treatment?
I’ll give you an example. Not too long ago, I had somebody who just felt like they couldn’t really leave their house if they had any redness on their face. They were just too embarrassed by it, and they thought everyone was looking at it. So for that I used exposure therapy, which is essentially learning how to expose yourself to the situation that causes fear and anxiety — but doing it in a very small, safe way. You do it incrementally, so that over time, your mind and body learn that you don’t really need to fear the thing you’re fearing. In my patient’s situation, eventually she was able to go out and spend time with people, and even consider dating.
Exposure therapy is a common way to treat anxiety, and so I think of what I do as almost like psychology with a twist. Sometimes I describe it as just very skin-focused psychotherapy.
Do you find then that when you address some of those root issues with people, that as a byproduct, their skin improves? Some do, some don’t. When we think about skin-picking issues, for instance, that’s caused by a number of reasons, some genetic. Some things are out of people’s control. But some is based on their experience in life, and how they’re managing their stress, how they manage anxiety, how they manage anger, how they manage their emotional states. So for them, I do a combination of some behavioral techniques, really working with that urge to pick. But also, what’s underneath that? What’s driving that?
In those situations, if I can help people really understand what’s at the heart of the problem, then they can go from compulsive skin picking to no skin picking at all. It can be quite amazing to see.
With your wart example, I wondered how much the placebo effect is part of that impact. When you have a breakout, if you assume it’ll keep getting worse and worse, are you in some way perpetuating it?
The placebo effect is certainly real. But my hunch is that it’s beyond placebo.
When we intensely imagine a situation as real, often our bodies respond. If I had you focus on putting a slice of lemon in your mouth, your body would react based on your thoughts. And if you talk to anybody who’s stressed or worried, and you bring up whatever they’re stressed about, their body reacts. So I think a similar thing is happening here. We can either catastrophize, and then our bodies respond to that, or we can learn how to calm things down, and we can learn how to manage it. In some cases, when you do that, yeah, your skin will actually change.
One clear example I see is when people come to me with psoriasis or eczema flare-ups, and I’ll ask when they first noticed the problem. It’s not uncommon for them to say it started when they were stressed. I’ll say, well, let’s work on that, and let’s see if we can begin to manage the stress related to that. And in some cases, people call me back after a few weeks having noticed that their skin isn’t flaring up as much.
It’s almost scarier to think that, instead of buying something, you might already have what you need to improve your skin. Because then it becomes about deeper issues and attending to those needs.
I think that’s kind of the hard part about psychotherapy in general. It’s much easier to just take a pill, or in this case, put some cream on. And I think if you can get a quick fix, that’s great. That’s wonderful. But there are also a lot of people out there who might be using makeup to cover their skin, but they’re really covering up psychological issues and concerns.
Of course, if that’s helping you, great. Any help is help. I really do believe that. But I also think that sometimes, getting to the root of things makes it so you don’t have to go out and buy every product. There are people who have spent years finding products all over the world to fix something that wasn’t actually their skin. It was about them, and how they feel about themselves and their skin.
This conversation has been edited for clarity and length.
